Diagnosis and Treatment of Venous Disease Part 1 of 2 by Domenic A. Zambuto, MD, RPVI, Regional Medical Director
There has been a dramatic shift in the approach taken for both the diagnosis and treatment of venous disease over the last 15 years. With this shift, there are now true centers of excellence that are bringing state of the art care to patients seeking proper management of their varicose vein disease. The new approach to comprehensive vein care results in much better outcomes, far more safety and much less “down time” than the older approaches.
This article discusses the evolution of vein care and the state of the art approach to proper diagnosis and treatment of superficial venous insufficiency (varicose vein disease). This article should serve as a guide for those seeking advice and treatment for their vein disease as it will help identify best practices for obtaining quality care. Ultimately all patients need to discuss their concerns with a qualified care provider.
Prior to 2001, there was very little interest in the treatment of superficial vein disease in the United States. Treatment options were limited to stripping surgeries (removal of the diseased vein), sclerotherapy (injecting the diseased veins with a drug to make them go away) and conservative measures including the use of prescription stockings. Each option had limited success and significant downsides. Most doctors had little interest in vein care due to the lack of good therapy and the perception that venous disease was mostly a cosmetic concern.
Surgical stripping procedures had a significant amount of problems and had limited success. The concept behind the stripping procedures was to decrease the amount of abnormal venous blood flow in the leg by removing the diseased veins. Eliminating the abnormal blood flow is still the concept of therapy for all treatment approaches for vein disease.
Most patients would undergo surgical stripping procedures in the operating room at local hospitals. Most patients would spend at least one night in the hospital post procedure. Most patients would have significant downtime typically being out of work from 1 to 2 weeks post procedure and not back to their normal activities for at least six weeks. Complication rates were estimated to be twice the complication rate of modern procedures.
It is estimated that there was a 40% failure rate of the stripping procedure in the first year. Given the poor performance of this procedure, it was reserved for patients who had serious vein problems such as recurrent blood clots, bleeding episodes and nonhealing wounds(ulcers) caused by their vein disease.
Sclerotherapy is a procedure used to treat small to medium sized veins. The abnormal veins would be injected with a medication designed to close the vein down. The vein would go into spasm and would die. The vein would then be absorbed by the body over time. This procedure was mostly used for veins that were visible at the skin surface.
The biggest issue over the years was the type of medication available. For a long period of time, there was limited availability of appropriate medications to treat veins with sclerotherapy. Strong salt solutions (hypertonic saline) were sometimes utilized. These earlier medications carried a substantial risk of complications.
As vein disease involves a tissue layer from the skin down to the start of the muscle layer only treating visible veins was often inadequate. Sclerotherapy would have limited success if the larger veins below the skin surface we’re not appropriately treated first. Because sclerotherapy was originally only used to treat visible veins on the skin surface it was in general viewed as cosmetic and was not covered by insurance companies.
Some people tried to perform sclerotherapy on the larger veins that were usually treated with stripping. This almost never worked. This is because those larger veins have a very thick wall structure that is not adequately treated by sclerotherapy solutions. In state of the art practices, sclerotherapy is used to treat a substantial portion of medically significant medium and small-sized superficial diseased veins and is far from being “just cosmetic”. The newer use of ultrasound to guide treatment of veins below the skin surface (making them invisible) has made sclerotherapy an important part of a proper medical treatment of vein disease in the modern era.
Conservative therapy included the use of gradient compression stockings, frequent walking, leg elevation and the use of anti-inflammatory medications (ibuprofen etc.). The stockings were designed to squeeze the abnormal superficial veins (the varicose veins) partially closed. By compressing the abnormal veins closed the stockings limit the abnormal blood flow down the leg. This is much like the way pinching a garden hose results in limited flow through the hose.
To be effective (to help control symptoms and to slow down the progression of the disease process) it is required that the stockings be worn while you are upright. Most people find the use of prescription stockings all day every day for life to be very challenging to comply with. It is for this reason that most people fail conservative therapy.
Entering the new millennium a small group of individuals was looking for a new way to approach vein disease. They were looking for a better way to perform strippings as a way to eliminate the abnormal blood flow in the diseased veins. They wanted something minimally invasive and looked to catheter-based technology.
The idea was to treat veins that were previously stripped with small catheters. This would avoid large scars and perhaps lower the threshold for people getting treatment. This resulted in two competing technologies; radiofrequency and laser catheter-based endovenous ablation. Both treatments heated the vein to the point of death of the vein wall. The vein was closed with blood flow shut off immediately. The body then absorbed the treated vein over the course of a year. These procedures worked well.
Early research studies looked at how well this technology would perform compared to the gold standard of stripping surgery. It was assumed the new technology would be inferior. It was not. Very quickly people realized that the new endothermal ablation techniques were far superior to the old stripping surgery. The combination of less risk, higher success rates, and minimal downtime resulted in the rapid replacement of stripping surgeries with either endovenous laser or endovenous radiofrequency ablation.
The two technologies were also shown to be essentially equal in their success and complication rates. Both technologies have also improved substantially from their originally available systems.
As time went on there was a real push to further understand chronic superficial venous insufficiency (varicose vein disease) and how to best manage the disease. What has become obvious is that most (but not all) people with this disease will have visible varicose and or spider veins. Most will have clinical symptoms that are significant.
Symptoms can include pain, aching, itching, fatigue, tiredness, heaviness, cramping, swelling and restlessness. Some will develop complications from the disease such as bleeding from a varicose vein, blood clots (phlebitis) and wounds that will not heal (ulcers). Most who do have clinical symptoms related to their vein disease will have treatment options covered by their insurance.
A better understanding of the disease, the thought process behind the best strategies for treatment and the long-term expectations on managing this disease will best help patients when choosing a care provider.
Continue with part 2 of Diagnosis and Treatment of Venous Disease.
You can find Dr. Zambuto at the Vein Clinics of America clinic in Canton, CT and you can reach his office by calling (860) 693-4060.